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Based on surveyor observation, record review and staff interview it has been determined that the hospital failed to ensure the safety of all patients, staff, and visitors in accordance with 42 CFR 482.41 Conditions of Participation: Physical Environment related to multiple areas throughout the hospital noted to have water leaking in from the roof. Additionally, it was determined that the facility failed to maintain a safe environment by maintaining compliance with the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC). Please refer to the FORM CMS-2567 Life Safety Code report.

1. During the survey a finding which constituted an Immediate Jeopardy (IJ) was identified relative to a surveyor observation on 3/29/2024 at approximately 1:15 PM of the hospital laboratory that revealed water leaking from the ceiling into a 2' x 4' recessed florescent light fixture which was connected to power. Additionally, multiple wet ceiling tiles were observed surrounding the light fixture, and water was running down the sides a concrete column.

Further observation of the laboratory revealed additional areas where water was leaking. A floor covering with a waste basket placed on top of it was collecting the leaking water. Additionally, observation of a window in the endoscopy (patient care area) revealed a sopping wet blanket on the windowsill, which was placed there to absorb the rainwater that was leaking in from the window.

The hospital Risk Manager and Maintenance Director were informed of the Immediate Jeopardy that was identified on 3/29/2024. The Hospital Risk Manager was provided with the Immediate Jeopardy template on 3/29/2024 at approximately 2:15 PM.

2. During an environmental tour of the hospital, the corridor in the operating room was noted to have two large, covered barrels with hoses running up into the drop ceiling. This hose was connected to leak diverters within the ceiling. These covered barrels were collecting the water that was leaking into the hospital from the roof. Similar barrels with hoses were observed on the Center 4 patient care unit, Center 3 patient care unit, the hallway leading to the laboratory, and in the back of the cafeteria. Additionally, a large pool of water was observed to have accumulated from rainwater leaking into the hospital through a wall observed in the first-floor hallway outside of the Women's Rest Room, near the conference room.

(Refer to A-0701)

Based on surveyor observation, record review and staff interview, it has been determined that the hospital failed to ensure that the physical condition of the hospital was maintained in a manner to ensure the safety and well-being of the patients, staff, and visitors.

Findings are as follows:

During a tour of the hospital on 3/29/2024, surveyor observations revealed rainwater infiltrating several areas in the hospital from multiple roof leaks.

The Affected areas included the Operating Suite, Laboratory, Center 4 Patient Unit, Center 3 Patient Unit, Cafeteria, Ladies Room first floor near the conference room, ground floor corridor leading to the laboratory and the endoscopy suite. Additionally, there were two other areas in the core lab where the rainwater was entering the lab from the ceiling. Absorbent pads were observed on the floor, as well as waste baskets to collect the rain water were positioned under the areas with leaks. Water damage was observed on the walls, windows, windowsills, and ceiling tiles during the tour. Life Safety Code Citations were identified in conjunction with this survey.

1. During tour of the hospital laboratory located on the ground floor in the diagnostic wing, cytology section, with the Risk Manager and the Maintenance Director on 3/29/2024 at approximately 1:15 PM, the surveyors observed an area of the ceiling where a 2' x 4' recessed florescent ceiling light was noted to have water in the fixture, which was connected to power. Additionally, there were multiple wet ceiling tiles surrounding the light and water running down the sides the concrete column adjacent to it.

At approximately 1:30 PM on 3/29/2024, the Manager of the Lab, was interviewed by the surveyors. He stated that there are multiple areas in the lab where they have ongoing issues with leaks when it rains. He informed the surveyors that the maintenance department was made aware of the leaks in January, and work orders had been submitted relative to leaks in the cytology section of the lab. Additionally, he stated that he had spoken with the Maintenance Manager who was also aware of the leak and had informed him that someone from the roofing company would be in next week. He informed the surveyors that the water leaks throughout the hospital have been an ongoing issue when it rains.

A Review of the work requests provided to the surveyor revealed multiple work order requests requesting repair of the roof due to leaking rainwater revealed work orders for areas throughout the hospital since January 2024.

During surveyor interview with the Director of Maintenance at the time of the observation, he stated that he was unaware of the leak in the cytology area of the lab. Although the Director of Maintenance informed the surveyors that he was unaware of the leaking roof in the cytology area of the lab, review of a work request provided to the surveyors revealed a work order (WO) request had been submitted to the maintenance department relative to the concrete column and ceiling leak in the cytology area of the lab dating back to 1/11/2024.


The above finding of the water in the recessed light fixture in the cytology area of the lab, constituted an Immediate Jeopardy (IJ). The hospital Risk Manager, and Maintenance Director were informed of the Immediate Jeopardy identified on 3/29/2024. The Hospital Risk Manager was provided with the Immediate Jeopardy template on 3/29/2024 at approximately 2:15 PM. During the surveyors return to the laboratory with the Director of maintenance on 3/29/24 at approximately 3:30 PM to verify the immediate corrective action had been implemented related to the light fixture containing water in the cytology area of the lab, another barrel with a hose connecting it to the ceiling was observed in the hallway leading into the lab. When questioned about how long this barrel and diverter system had been in place, he stated that he was unaware of the barrel in this area. He stated the barrels are placed to catch the rainwater when a leak is identified.

2. During a tour of the operating room (OR) with the operating room Nurse Manager and the Risk Manager on 3/28/2024 at approximately 11:15 AM, relative to a complaint, the following was observed:

The main area (corridor) in the OR, where the scrub sinks are located, and 8 OR suites are located, as well as supply rooms, was noted to have two large, covered barrels with garden hoses observed to be running up into the dropped ceiling and connected to leak diverters in the ceiling to contain the rainwater. Barrels were observed to have a cover with a hole cut in the center of the cover where the garden hose was placed to drain the water.

During surveyor interview with the OR Nurse Manager, at the time of the observation, she informed the surveyor that the barrels have been in the OR since she started to work at the hospital in July of 2023. She stated that the maintenance department takes care of emptying the barrels when needed.

During a tour of the OR, an interview was conducted with the Infection Control Nurse regarding the barrels present in the OR suite. He stated that he was aware of the barrels and did not have any infection control concerns relative to the barrels being present there. He stated that the roof needs to be repaired or replaced, and the hospital is diverting the rainwater by the use of a roof diverter funneling the water into the barrels.

During surveyor interview with the Maintenance Director who came to the OR during the tour on 3/28/2024, he stated that these leak diverters are an approved system and used in many buildings to collect water from leaks.

A Review of the 9/6/2023 Operating Room Committee Minutes, revealed; "Discussion Physician Issues: Barrels in the operating room hallways that collect water leaks are an ongoing issue". The Outcome/Action Plan states "This was explained we need a new roof".

3. During the surveyor tour of the hospital on 3/29/2024, which included a CMS certified Life Safety Surveyor, Director of Maintenance, and the Risk Manager the following issues were observed:

-The Center 4 Patient Unit, in the hallway in front of the nurse's station, a leak diverter system was observed in the ceiling with 4 plastic covered buckets with white hoses connected from the ceiling down into the buckets to collect the rainwater.

-On the Center 3 patient unit, in the hallway in front of the nurse's station was observed to have a leak diverter system in the ceiling and a plastic covered buckets with a hose connected from the ceiling down into the bucket to collect the rainwater.

-On the Endoscopy suite, a window was observed in a patient care area, where water was leaking in through a window and staff had placed a blanket on the windowsill to contain the water which was noted to be saturated with rainwater.

-The cafeteria revealed a large barrel with a garden hose connected to the ceiling leak diverter, which was brought to the attention of the Risk Manager and the Director of Maintenance, who were unaware of the water leak.

-A large ponding of water was noted in the first-floor hallway outside of the Ladies Room, near the conference room, due to rainwater leaking into the building through the wall. This area had caution wet floor signs around the large area of water.

On 4/2/2024, at approximately 11:10 AM, the surveyors accompanied by the Director of Maintenance observed the wall in the lady's room/locker area. The wall was noted have several holes from water damage, as well as water damage along the length of the wall. Blankets were in place on the floor against the wall to collect the leaking water.

During a surveyor interview with Director of Maintenance and the Manager of Maintenance on 4/2/2024, the Director informed the surveyors that "everyone is aware of the issues with the water leaks from the rain" he stated he is on the Safety Committee and has reported the issues with the water leaks and that the hospital has the roof repairs in the Capital Budget.

A Review of the Safety committee minutes from March 2023 through February 2024 revealed no documentation of the water leaks.

The above findings constitute condition level deficient practice.